Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
The patient was a 76-year-old woman with a history of atrial fibrillation and cerebral infarction. On March 7, 2016, she was admitted to our hospital’s orthopedicsurgery ward to undergo surgery for gonarthrosis, and was referred to ourdepartment for a perioperative cardiovascular evaluation for noncardiac surgery.
Relevant test results prior to catheterization
Blood tests revealed Stage 3 chronic kidney disease with Cr 1.17 (e-GFR 34.7 ml/min/1.73 m3）but no other notable findings. The ECGrevealed atrial flutter. Ultrasound examination also revealed a left ventricular ejection fraction of 53% and mild hypokinesis of the posterior inferior wall.
Relevant catheterization findings
RCA: 99% stenosis in seg. 3
LMCA; 25-50% stenosis from mid to distalportion
LAD: 75% stenosis in seg. 6, 50% stenosisin seg. 7
LCx: 75% stenosis in seg. 13, 90% stenosisin seg. 15
(Collateralcirculation from the LCA in the direction of the RCA was also revealed.)
Taking the right radial artery approach, the LCA was engaged by a 6Fr. Voda Left 3.5 (Mach 1). The first shot after engagement led to dissection of the LMT, with the dissection extending to the LAD and the LCx. A wire was immediately passed to the LCx, and POBA was performed, but pulse rate soondropped to the 20s, and blood pressure on the pressure monitor was nearly flat.While performing CPR, an IABP was inserted and vital signs became stable. In the angiography after CPR, the GC was dislodged and the wire had also beenremoved, but using the parallel wire technique it was possible to pass a wire through the true lumen. From the peripheral segment of the LAD, ResoluteIntegrity 3.0/26mm and 3.0/30 mm stents were placed, followed by Resolute Integrity 3.0/26 mm and 3.0/18 mm stents from the peripheral segment of the LCx. In addition, Resolute Integrity 3.0/22 mm was placed in LCX seg. 11 and Resolute Integrity 3.5/26 mm in LMT-LAD seg. 6, and through mini crush stenting, bailout became possible. Following this, the patient progressed with a max CK of 1001, and after rehabilitation, PCI was performed for the RCA. She was able to walkout of the hospital unassisted upon discharge.
The first shot after engagement led to dissection of the LMT, with the dissection extending to the LAD and the LCx, causing hemodynamic failure during the procedure. It was revealed that the dissection had already extended to the peripheral LAD and LCX, there was the possibility that stenting of theLMT alone would not result in reperfusion and would also obstruct stent placement in the peripheral segments of the LAD and LCx, and make it difficult to treat the LMT bifurcation. Stents were thus placed from the LAD and LCx peripheral segments, after which Mini crush stenting of the LMT bifurcation was performed to achieve revascularization.